Provider Demographics
NPI:1366066441
Name:GANUB, TANISHA J
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:J
Last Name:GANUB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 581014
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-0017
Mailing Address - Country:US
Mailing Address - Phone:916-825-2545
Mailing Address - Fax:
Practice Address - Street 1:1803 W MARCH LN STE C&D
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6414
Practice Address - Country:US
Practice Address - Phone:209-636-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty